Guideline For Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms
3rd Edition, for Adults over 18 years of age
General considerations
Mental health disorders are common following mTBI, and appear to be major determinants of post-mTBI wellness and functional recovery. This includes disorders of mood which consist of symptoms related to depression and anxiety. The etiology of mTBI/concussive mood disorders may be related to reactive or environmental factors such as the experience of the trauma resulting in the injury (e.g., manifesting in post-traumatic stress symptoms, phobias and related anxieties) or to the negative outcomes following the injury (i.e., depression related to not participating in important roles such as work or school, sports, etc.) They may also manifest in response to the chronic symptoms that can follow concussion/mTBI or any physical injuries such as poor sleep, persistent headaches, chronic pain, medications, etc. Indeed, all of these types of outcomes can contribute, causally, to distress and to disorders of mood. Reciprocally, in what can be considered a ‘vicious cycle of pathology’, disorders of mood can exacerbate chronic pain, sleep disturbance, anergia and cognitive inefficiencies. This approach to considering disorders of mental health is important when attempting to holistically assess for and manage an individual’s outcomes post-mTBI. The disorders of mood related to increased irritability, intolerance, reduced patience and mood reactivity may be related to the neurobiological impact of the injury and/or a reaction to challenges of managing stimulation early on following the injury.
Mental health symptoms and outcomes must be understood within the biopsychosocial context of the individual and that multiple factors can influence related mental health disorders. In the case of mTBI, biologically the individual may suffer an insult to the brain and injuries to the body (e.g., whiplash injuries, etc.), with consequences to their experience of pain and ability to sleep, which can further cause changes in the neurobiology of the brain. At the psychological level they may experience acute stress due to their experience of trauma or injury, as well as in response to the consequences to their functional abilities resulting from the injury. People with persistent symptoms may become isolated from others as they may be intolerant of or unable to engage in social interactions. Their injury status may disrupt their occupational status, leisure activities and interpersonal interactions. They may also incur losses (e.g., reduced quality of life and independence; lowered income or reduced educational attainment; changes in relationship functioning, etc.). When assessing and managing disorders of mental health post mTBI, it is important to consider all of these potential factors; additionally, individuals who have suffered an mTBI may also have a pre-existing history of biopsychosocial factors/issues that may affect the expression of mental health symptoms or the duration of recovery including the ability to return to pre-injury status.
It is often difficult to obtain timely assessments and treatment interventions from mental health experts. Delays can, and often do, contribute to worse outcomes, and so it is important that primary care providers intervene as soon as possible. Screening for mental health symptoms and determining their etiology as well as prescribing treatment is crucial to facilitating a positive recovery. For example, in a primary care setting this may include screening for disturbances of sleep, or presence of chronic pain, loss, metabolic status etc when patients report low affect. Intervening at the level of improving sleep, managing pain and correcting metabolic imbalances may result in improving reports of low affect. If psychological and social issues appear to be causing mental health symptoms then appropriate therapeutic and/or medication strategies should be employed.
Finally, there is no current evidence to indicate that the mental health problems of individuals who have suffered an mTBI should be treated any differently than mental health problems of other etiologies. For example, we do not have evidence that Major Depressive Disorder (MDD) post-mTBI should be treated differently than MDD that may develop for other psychosocial or biological factors. As such, pharmacological and nonpharmacological interventions including therapeutic interventions that have been found to be helpful in the general population should be considered for individuals who have developed mental health problems post mTBI. Strategies used to treat mental health symptoms post concussion/mTBI should follow the same logic as that applied to similar symptoms found secondary to their conditions or circumstances which include the potential for treatments to worsen other mTBI outcomes. For example, some antidepressant medications, particularly those that are more sedating and/or have greater anticholinergic activity, can worsen the anergia and cognitive impairments that arise directly from mTBI. Another example is the concern for exacerbating seizure risk; fortunately, seizures are a relatively rare outcome of mTBI (although one that must be considered and, depending on the history, assessed for when considering certain psychotropic medications). Some medications can also contribute to worsening of balance impairment, or dizziness, and other symptoms. The need, then, is to select treatment interventions for which there is some evidence of efficacy(often this will be derived from studies done in the non-mTBI population) while carefully considering and assessing for, the potential to exacerbate other mTBI-related outcomes. In general, psychotropic medications should be used with caution, and non-medication options selected as much as possible. If selecting a medication intervention, start at low doses, allow adequate time for response to be assessed for, and carefully monitor for both efficacy and side effects.
Assessment
Acute concussive symptoms can include irritability, anxiety, emotional lability and depressed mood.1-3 Early education and treatment focused on symptom management is important. If symptoms persist, the risk of increasing symptom intensity is heightened manifesting in more severe mental health symptoms such as Major Depressive Disorder (MDD) and Post- Traumatic Stress Disorder (PTSD).4 Depressive disorders following TBI are commonly associated with increased irritability and often comorbid with anxiety symptoms as well as with fatigue, sleep disturbances, cognitive dysfunction, decreased mobility, emotional processing deficits and anxiety syndromes. The latter include generalized anxiety, panic attacks, phobic disorders, and post-traumatic stress disorder (PTSD).2,3,5 These disorders comprise both new conditions that develop de novo post-injury, as well as those reflecting an exacerbation of pre-injury conditions or vulnerabilities.1
Regardless of etiology these disorders require prompt recognition, identification and treatment, given their frequency and potential to impede recovery in other symptom domains1,6 as well as result in significant functional declines. Pre-existing difficulties such as substance use disorders and poor psychosocial adjustment also place patients at risk for a protracted recovery or a recovery that is much longer than expected.7-9 Females on average take longer to recover and are at higher risk for anxiety and depressive disorders after TBI.4,9,10 Delays in returning to social and vocational roles can in turn produce demoralization and worsened emotional symptoms.1,4,11
The assessment of mental health disorders can be challenging given the overlap in symptoms between mood disorders, sleep disorders, pain syndromes, as well as cognitive difficulties. “Subthreshold” variants of certain conditions, particularly anxiety-based disorders such as PTSD are also observed, in which a symptom cluster falls short of meeting formal diagnostic criteria for a more commonly known disorder, but diagnostically fall into other trauma-related syndromes and require treatment. In general, it is recommended that DSM 5 diagnostic criteria be applied in an “inclusive” manner: for example, counting all relevant symptoms toward a potential diagnosis of depression, regardless of whether the mTBI alone could have caused the symptom12,13 Potential contributing medical conditions should also be identified, such as anemia, thyroid dysfunction, B12 deficiency, and so forth. If a mental health condition exists appropriate care should be provided or appropriate referrals made. In situations of diagnostic uncertainty, appropriate referrals should be made.
Various self-report questionnaires can aid the clinician in assessing mental health disorders and offer the advantage of yielding criterion-based diagnoses as well as severity ratings to monitor progress: the Patient Health Questionnaire 9-item scale (PHQ-9; Appendix 8.1) for depression; the Generalized Anxiety Disorder 7-item scale (GAD-7; Appendix 8.2) and the short Primary Care PTSD Screen (PC-PTSD; Appendix 8.3) or the longer PTSD Checklist (PCL-5; Appendix 8.4); and the CAGE-AID questionnaire for substance use (i.e., alcohol; Appendix 8.5). Note that these questionnaires have not been validated specifically with the mTBI population.
Management
Treatment is indicated when symptom levels cause distress and negatively impact interactions, function and quality of life or clearly are impeding recovery. Once identified, appropriate psychological and/or pharmacological treatment should be initiated. Medication consultation can be provided by a psychiatrist while therapy interventions may be provided by psychologists or other mental health specialists. Treatment should be initiated early to reduce the risk of worsening symptoms and/or having symptoms become entrenched. Medical issues should be managed concurrently such as headaches, dizziness and comorbid pain. Immediate approaches should include concussion/mTBI education regarding the positive expectations for recovery as well as general support, validation and reassurance.14-17 Involvement of the family can be very helpful at this stage. Education about regular light exercise should be provided, as well as other important lifestyle information including balanced meals, keeping a routine, seeking social support, etc. General lifestyle measures can have some positive effect on mood, perceived fatigue and well-being, and can counteract deconditioning. See Algorithm 8.1, which outlines care pathways for mild to moderate and severe mental health disorders following concussion/mTBI.
Non-Pharmacological (Psychosocial) interventions
Psychological interventions are critical in the management of primary mental health disorders and include counselling and formal psychotherapies. Cognitive behavioural therapy (CBT) refers to a structured set of strategies focused on managing negative emotion and building coping strategies by altering maladaptive thought patterns and behaviour. There is robust support for the efficacy of this treatment across a range of mental health conditions which include those affecting individuals with concussion/mTBI (e.g., various types of depression and anxieties, insomnia, chronic pain, etc.) with some modifications in procedure indicated for individuals with cognitive challenges.9,17-19 The psychotherapeutic intervention applied should be appropriate for the mental health condition diagnosed post concussion/mTBI.20
The decision to recommend psychological intervention will depend on factors such as patient preference and motivation, symptom severity and comorbidity, skills and experience of the treating clinician, and the ease of access to such resources. Primary care providers may be well-suited to provide supportive counselling, along with low-intensity interventions based on CBT principles.21 For more difficult symptom presentations cases, such as moderate to severe depression or anxiety, persistent PTSD, or the presence of complex comorbities referral for specialist treatment should be sought. Combined treatment with medication may also be appropriate.
Pharmacological interventions
Medication may be required for those with moderate to severe, persistent depressive or anxiety symptoms. Selective serotonin reuptake inhibitors (SSRIs) and Serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended as first-line treatments for diagnosed mental health conditions following concussion/mTBI, based upon their side-effect profile and broader utility when compared to agents from other classes.9,22 Current evidence supports the utility of SSRIs and SNRIs in treating depression, reducing anxiety and irritability, and, in some reports, improving cognition, somatic symptoms and psychosocial function.22 The efficacy and tolerability of both sertraline23 (starting at 25 mg; aiming for 50-200 mg/day) and citalopram (starting at 10 mg; aiming for 20-40 mg/day) is supported within the mTBI literature.1,24 Common clinical experience suggests that other agents (e.g., alternate SSRIs, venlafaxine, mirtazepine) may also be useful for diagnosed mental health conditions following mTBI, yet clinical data with these agents is lacking. There are no studies indicating specific medication treatment for PTSD for individuals with concussion/mTBI, yet the use of sertraline, paroxetine and venlafaxine are supported by high-quality evidence in the non-TBI population.22,25 In the absence of additional data specific to TBI, the use of treatment algorithms developed for primary mental health disorders may be appropriate, albeit with some qualifications.
The concussion/mTBI population may be more sensitive to adverse medication effects upon cognition (alertness, attention, memory), balance and dizziness, sleep and fatigue, and headaches. Anticholinergic effects of certain tricyclic medications (e.g., amitriptyline, imipramine, doxepin) should be carefully monitored. Although uncommon, the risk of post-traumatic seizures (epilepsy) after concussion/mTBI remains elevated and accounts for 10–20% of epilepsy cases in the general population26 at about 1.5 times the rate for the general population for 1-4 years after injury.10 Up to 86% of patients with one seizure after TBI will have a second seizure within 2 years of their injury.27 Medications with greater impact upon the seizure threshold, such as clomipramine, maprotiline, and the immediate-release formulation of bupropion, should be avoided in favour of newer agents.28 The use of benzodiazepines as first-line therapy or in the long-term treatment for anxiety, agitation or aggressiveness after concussion/mTBI is generally not recommended due to potential effects on arousal, cognition, and motor coordination.24,29 The potential for abuse/dependency associated with these agents is also of concern, given the elevated rates of pre-injury substance use disorders observed among TBI patients.9,24 Nonetheless, short-term use of these agents may be helpful during periods of crisis or acute distress.
Strategies related to discontinuation of pharmacoptherapy should be based on guidelines appropriate to the diagnosed mental health condition. Special consideration is not currently indicated for concussion/mTBI.30 In the absence of strong reasons for early termination (such as tolerance issues), successful pharmacotherapy should be continued for at least 6 months before a trial of slow tapering is considered. Relapse prevention strategies should also be considered with psychological treatment approaches
8.1
In assessing common post-concussive mental health symptoms, determine whether the symptoms meet criteria for the presence of common mental health disorders, which include but are not limited to:
Elements of the assessment should include taking a comprehensive history (including discussion with support persons), structured clinical interview, use of self-report questionnaires, and behavioral observation.
8.2
If a mental health disorder is determined to be present, then the treatment of the emotional/behavioural symptoms should be based upon individual factors, patient preference, symptom severity and comorbidity, and existing practice guidelines for the treatment of the diagnosed condition (e.g., depression, anxiety, PTSD).
Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2009).
8.3
Immediate referral to a regulated mental health practitioner should be obtained if:
It is not necessary for the mental health practitioner to be someone who has a specialty in the treatment of concussion.
8.4
While awaiting specialist referral, the primary care provider should clinically manage:
8.5
Cognitive behavioural therapy (CBT) and other psychotherapeutic modalities have well established efficacies for the treatment of primary mood and anxiety disorders in the mental health and other neurological populations; with emerging evidence in the post-concussive population. Given the evidence, psychotherapy should be recommended for patients with persistent mood and anxiety issues following concussion.
8.6
When prescribing any medication for patients who have sustained a concussion/mTBI, the following should be considered:
For more details regarding pharmacotherapy after concussion/mTBI, refer to Table 8.1.
Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2009).
8.7
A SSRI is generally recommended as the first-line pharmacological treatment for mood and anxiety syndromes after concussion/mTBI. In some cases, however, the combination of sedative, analgesic, and headache prophylaxis effects from a tricyclic (TCA) may be desirable, yet these agents may generally be considered second-line. Other second-line options include mirtazapine, an alternate SSRI, or an SNRI.
8.8
After successful treatment with an antidepressant, maintenance treatment for at least 6-9 months is advised to reduce the risk of relapse.
8.9
SSRIs or SNRI’s are recommended as first-line pharmacotherapy for PTSD after concussion/ mTBI; both can improve the core symptom of re-experiencing, hyperarousal and avoidance.
Haarbauer-Krupa J, Taylor CA, Yue JK, et al. Screening for Post-Traumatic Stress Disorder in a Civilian Emergency Department Population with Traumatic Brain Injury. J Neurotrauma. 2017;34(1):50-58.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *7 of the sections were not applicable
Iverson KM, Pogoda TK, Gradus JL, Street AE. Deployment-related traumatic brain injury among Operation Enduring Freedom/Operation Iraqi Freedom veterans: associations with mental and physical health by gender. J Womens Health (Larchmt). 2013;22(3):267-275.
Country: USA
Design: Survey
Quality Rating: DOWNS & BLACK: 17/32 *6 of the sections were not applicable
Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013;28(1):13-20.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 17/32 *5 of the sections were not applicable
Bedard M, Felteau M, Marshall S, et al. Mindfulness-based cognitive therapy reduces symptoms of depression in people with a traumatic brain injury: results from a randomized controlled trial. J Head Trauma Rehabil. 2014;29(4):E13-22
Country: Canada
Design: Randomized Control Trial
Quality Rating: PEDro: 7/11
Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016;61(9):540-560.
Country: Canada
Design: Non-Concussion/mTBI Guideline
Quality Rating: N/A *No checklists were appropriate to score this article design
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